Healthcare Provider Details

I. General information

NPI: 1033326947
Provider Name (Legal Business Name): KANWALDEEP SIDHU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 10/15/2022
Certification Date: 10/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10765 LANTERN ROAD SUITE 102
FISHERS IN
46038-3597
US

IV. Provider business mailing address

10765 LANTERN ROAD SUITE 102
FISHERS IN
46038-3597
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-4181
  • Fax: 317-621-4182
Mailing address:
  • Phone: 317-621-4181
  • Fax: 317-621-4182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01066327 A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: